Citation Nr: 20007516
Decision Date: 01/29/20	Archive Date: 01/29/20

DOCKET NO. 17-04 989
DATE: January 29, 2020

REMANDED

Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded.

REASONS FOR REMAND

The Veteran served on active duty from July 1982 to May 1986.

This matter comes before the Board of Veterans' Appeals (Board) from a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). 

In October 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is associated with the Veteran's claims file. The Veteran is claiming entitlement to service connection for PTSD, which he contends is related to an in-service military sexual trauma (MST). During the hearing, the Veteran testified that he was sexually assaulted by his staff sergeant but was dissuaded from making an official report. He reported alcohol and drug abuse thereafter, although he ultimately finished his tour of duty and received an honorable discharge.

However, while the Veteran testified at the October 2019 hearing that he had been going to a VA Medical Center for counseling, and a VA medical professional had given him a diagnosis of PTSD, those records are not associated with the claims file. Further, the Veteran was never given a VA examination regarding his psychiatric disorder; therefore, the Board finds a VA examination is required to discern a diagnosis for PTSD and opine as to the nexus between service and the diagnosis with adequate rationale.

Accordingly, the matter is REMANDED for the following action:

1.	Associate with the claims file all available treatment records from the East Orange VA Healthcare System (and associated outpatient clinics) from 2006 to the present.

2.	DO NOT PROCEED WITH THE FOLLOWING instruction until all actions and development requested above has been completed to the extent possible.

3.	After completion of the development listed above, schedule the Veteran for a VA psychiatric examination, to include an initial PTSD examination, to determine the nature and etiology of the Veteran's psychiatric disorders, to include PTSD, depression and anxiety (IF applicable).

The claims folder should be made available to the examiner for review in connection with the examination and the examiner should acknowledge such review in the examination report. Following interview of the Veteran and review of the claims folder, the examiner is requested to provide opinion on the following:

a.	If the examiner finds that the Veteran meets the criteria for a PTSD diagnosis in accordance with the DSM-5, he/she should specifically identify which stressors are linked to the PTSD diagnosis, including any stressors prior to or after service. 

b.	IF applicable, for each acquired psychiatric disorder identified, other than PTSD, provide an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the disorder was incurred in or is otherwise etiologically related to the Veteran's military service?

The examiner must consider the complete record, including the lay statements the Veteran submitted in 2019.

 

 

MICHELLE L. KANE

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Mireya Martinez

The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.